The Care Educator RN, under the direction of the Care Program leadership, coordinates, educates, and provides expertise to patients across the continuum of care from complex medical to chronic conditions as well as promoting compliance with preventative care measures. The Care Educator (RN) interacts with patients through various mediums including onsite face-to-face, telephonic encounters, and group workshops. Reinforces and empowers their patients to modify their behavior, assists them in navigating the complexities of the healthcare system, and how to use community resources. The Care Educator RN applies the principles of the Patient Centered Medical Home (PCMH) to prevent or delay severe stages of disease progression and enhance the member's quality of life. The role's focus is to reduce complications and morbidity, improve health outcomes, and reduce the cost of healthcare services for the patient.

Essential Job Functions

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Assist with the identification of patients who can qualify for a care program.
• Analyzes clinical information to identify members and to determine eligibility and appropriateness for enrollment in the Disease management Program.
• Perform direct and group patient education. Conducts individual and group education classes.
• Health Coaching and Lifestyle Management - Provide member education on disease process and healthy lifestyle changes; via phone call, texting messages and with individual or group coaching sessions via face to face or virtual to improve self-management of specific conditions that are consistent with clinical practice guidelines.
• Improve patient outcomes through various outreach channels. Focus on wellness promotion and provides education regarding age-appropriate preventive care measures in collaboration with the primary care team.
• Promotes patient self-management of disease and behavior modification interventions.
• Performs patient follow up and monitoring according to patient health risk status as stated in program policy. Educates patient and family/caregiver(s) about relevant community resources.
• Adheres to department policies and procedures.
• Participates in staff and department meetings monthly. Confers with other members of the healthcare team regarding patient care and work in collaboration towards non-compliant population. Shares professional knowledge and learning with other team members.
• Patient Care - Conducts a thorough needs assessment, including risk stratification to determine health, psychological, educational, and social needs, and the level of care requirements to establish an individualized care plan.
• Ensures patients receive the appropriate services based on their individual needs and develops an individualized care plan.
• Collaborates with the Center Team including Providers and Medical Directors.
• Participates in team huddles to review strategies, identify patients or providers with immediate needs and develop a plan of action to provide quality care. Complete electronic referrals, medication refills, and send to primary care providers as appropriate.
• Assess the patient's progress toward individual health care goals, to optimize patient adherence to medical plan of care, including medication adherence, evidence-based care, and specific screenings for recommended preventive care.
• Monitor and Report Disease Management activities, goals, and outcomes. Establish Specific, Measurable, Achievable, Realistic and Time bound goals that address identified needs.
• Improve patient's quality of life and promote evaluation of the cost and quality outcomes of the care services provided.
• Documentation and Compliance - Maintain requirements of documentation as reflected in audits to meet compliance with quality standards and acknowledges patient's rights on confidentiality issues, always maintains patient confidentiality, and follows all HIPAA guidelines and regulations. Maintains documentation in compliance with federal, local, and organizational policies.
• Community Resource Support - Determines and provides relevant community and/or health care resources that help support theory of change and effective and efficient utilization of health care. Provides patient resources as an aid to achieving positive health outcomes.
  
  

• Proficient software computer skills to include WORD, EXCEL, and other Microsoft Office programs.
• Must have passion for education, portray excellent listening skills, and maintain standards for professional nursing practice and demonstrate the ability to use the nursing process.
• Any combination of education, training, and experience which demonstrates the ability to perform the duties and responsibilities as described including related work experience.

Nice to Have Skills

• ACLS/PALS certification preferred.
• Health Coach or equivalent certification preferred.

• Dependable
• Team oriented
• Leader

Medix is acting as an Employment Agency in relation to this vacancy.